Date Published

December 17, 2015

Updated For

ALS PCS Version ALS PCS Version 5.2


Question: I had a question about the ACP Pain Management Medical Directive. I can give 4 doses of 5mg max of morphine (a total of 20mg).  If I give a loading dose of let's say 4mg to achieve the desired effect then I could give maintenance doses of 2mg every 5 min to keep the patient's pain controlled. So instead of giving 20mg over 15 min I could give it over 40 min. This way I am giving a smaller dose, hopefully meaning I have less side effects (nausea, vasodilation) and if I have a longer transport time can better manage my patient's pain for longer. I understand that Base Hospitals are very strict about giving only 4 doses. Thank you. PS: I think this is a great tool!


Great question. There have been many studies published showing the need to do a better job of treating our patients pain and that pain is better controlled if started pre-hospital (1,2,7,8,10).  However, as you allude to, there is great variability in patient responsiveness to opiate analgesia.  There are also dose related side effects associated with opiate analgesia: hypotension, hypoxia, anaphylaxis, nausea, pruritus etc. (3,5).  Evidence-based guidelines for pre-hospital administration of morphine have found 0.1mg/kg IV to be the optimal dose to alleviate pain with minimal side effects (2,4,5,8,9).  These same guidelines suggest reassessing for further analgesic requirements q5min is both practical and safe (4).  There have been protocols in the literature for repeats of both ½ as well as equivalent of the initial dose (4,6,9).

We recognize that: (1) not all patients require repeated doses of 5mg and (2) limiting the max doses to four may not result in adequate analgesia in long transports.  Therefore we would recommend that additional doses of morphine be titrated to the patients analgesic needs. Additionally, we consider the maximum dose of 20 mg (5mg x 4) a hard cap requiring a patch to a BHP to exceed. Finally, we feel that on prolonged transports it is this hard cap and not the number of doses that is important to consider. Therefore, we would support more than 4 doses when those doses are given at lower amounts q5min so as not to exceed the dose maximum.

Bottom line: You may use more than 4 doses of morphine, repeating dosages q5min as needed, provided that the maximum dose does not exceed 20mg.  However, as always, should you encounter a scenario outside of the directive, you can always patch to get additional orders.


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Walsh et al. Paramedic attitudes regarding prehospital analgesia. Prehosp Emerg Care.  2012:17(1)-78-8



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